Bowel perforation is a life-threatening condition associated with
high morbidity and mortality rates. There are few data on colonic
perforations (CP) due to barotrauma with air or fluid inserted into the
anus via various devices. (1,2)

A 72-year-old man was referred to an emergency department (ED)
because of CP due to high-pressure water self-applied anally. On
presentation he complained of rectal bleeding and abdominal pain. His
general condition and vital signs were normal except for a raised heart
rate of 115 bpm. He had been constipated for a long time, and 8 hours
before the ED visit had attempted to flush out his colon using a
high-pressure garden hose. The hose had been inserted approximately
30-40 cm into the anal canal.

There was extensive guarding on palpation of the abdomen. An
ultrasound scan showed free fluid in the perihepatic and perisplenic
recesses, but no free air or air-fluid levels were seen on conventional
radiographs. Findings on digital rectal examination were normal. He
underwent surgery because oral and intravenous contrast-enhanced
abdominal tomographs revealed perforation proximal to the rectosigmoid
junction, associated with extensive intra-abdominal free fluid and free
air (Fig. 1). Ragged colonic tissue around a perforation of nearly 2 cm
in length, 20 cm proximal to the rectosigmoid junction, was excised and
repaired. He was discharged after an uneventful recovery.

Conclusion

Emergency physicians should have a high index of suspicion for
catastrophic intra-abdominal injuries, including colonic perforation, in
patients with rectal bleeding and severe abdominal pain. Peritoneal
signs due to faecal contamination can be a late finding after colonic
perforation. Factors such as psychiatric conditions should be kept in
mind when such injuries are encountered in the ED. These patients
require a detailed examination and investigations to reveal colorectal
injuries, and it must be kept in mind that peritoneal signs can be
delayed.

Ibrahim Turkcuer and Mustafa Serinken are Assistant Professors of
Emergency Medicine in the Department of Emergency Medicine, Pamukkale
University School of Medicine, Denizli, Turkey; Ozgur Karcioglu is
Associate Professor of Emergency Medicine in the Department of Emergency
Medicine, Acibadem University School of Medicine, Istanbul, Turkey;
Cagatay Aydin is Associate Professor of General Surgery in the
Department of General Surgery, Pamukkale University School of Medicine;
and Yilmaz Kiroglu is Assistant Professor of Radiology in the Department
of Radiology, Pamukkale University School of Medicine.